NCLEX : Taking and Interpreting Vitals

Study concepts, example questions & explanations for NCLEX

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Example Questions

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Example Question #1 : Taking And Interpreting Vitals

A 2+ radial pulse is considered to be __________.

Possible Answers:

A bounding pulse

A normal pulse

An absent pulse

A weak pulse 

Correct answer:

A normal pulse

Explanation:

The following scale applies to the amplitude of a pulse when palpated at the radial artery:

3+ is an increased or bounding pulse

2+ is a normal pulse

1+ is a weak pulse

0 is an absent pulse

Example Question #3 : Procedures And Care

Which of the following locations is most appropriate for assessing the pulse of an infant?

Possible Answers:

Brachial artery

Radial artery

Popliteal artery

Carotid artery

Correct answer:

Brachial artery

Explanation:

The most appropriate location for assessing the pulse of an infant is the brachial artery, which travels from the axilla down the ventral surface of the upper arm to the cubital fossa. The popliteal and radial pulses are difficult to palpate on an infant due to their size, and the carotid artery can be difficult to palpate due to an infant's shorter, thicker neck. 

Example Question #2 : Taking And Interpreting Vitals

Which of the following is a normal adult respiratory rate?

Possible Answers:

Correct answer:

Explanation:

Normal adult respiratory rate is 12-20 breaths per minute. A respiratory rate below 12 is defined as bradypnea, while a respiratory rate above 20 is considered tachypnea. 

Example Question #3 : Taking And Interpreting Vitals

What is a normal respiratory rate for an infant under 1 year of age?

Possible Answers:

10-20 breaths per minute

60-90 breaths per minute

20-30 breaths per minute

30-60 breaths per minute

Correct answer:

30-60 breaths per minute

Explanation:

Infants have the highest respiratory rate of any age group. A normal infant respiratory rate is 30-60 breaths per minute. 

Example Question #5 : Procedures And Care

How might an overlarge cuff affect a blood pressure reading?

Possible Answers:

There would be no significant effect

The reading would be artificially high

The reading would be artificially low

The reading may be unstable

Correct answer:

The reading would be artificially low

Explanation:

An overlarge blood pressure cuff will often result in a blood pressure reading that is artificially low. It is important that the nurse chooses the appropriate blood pressure cuff size for each individual patient.

Example Question #4 : Taking And Interpreting Vitals

While assessing a patient's blood pressure, what part of the stethoscope should be placed against the patient's antecubital fossa: the bell, or the diaphragm?

Possible Answers:

The diaphragm should be used first, then the bell

The diaphragm

The bell

The bell should be used first, then the diaphragm

Correct answer:

The diaphragm

Explanation:

When taking a patient's blood pressure, the diaphragm alone should be used to listen at the antecubital fossa. The bell, used for low-pitched sounds, would not give the examiner accurate enough information to assess systolic or diastolic pressure.

Example Question #5 : Taking And Interpreting Vitals

Which of the following would be considered a normal adult blood pressure?

Possible Answers:

132/88 mmHg

124/84 mmHg

110/72 mmHg

88/56 mmHg

Correct answer:

110/72 mmHg

Explanation:

Normal adult blood pressure is anywhere from 90-120 mmHg systolic over 60-80 mmHg diastolic. 120-140 mmHg over 80-90 mmHg would be considered pre-hypertension, while anything over that would be considered either stage I or stage II hypertension.

Example Question #6 : Taking And Interpreting Vitals

What is a normal respiratory rate for a child aged 1-6 years old?

Possible Answers:

24-34 breaths per minute

36-54 breaths per minute

12-24 breaths per minute

34-44 breaths per minute

Correct answer:

24-34 breaths per minute

Explanation:

A normal respiratory rate in a child aged 1-6 years is 24-34 breaths per minute. This is significantly higher than an adult normal respiratory rate, which is 12-20 breaths per minute. 

Example Question #8 : Procedures And Care

What is a normal heart rate for an infant under 1 year old in beats per minute (bpm)?

Possible Answers:

60-100 bpm

30-60 bpm

100-160 bpm

160-240 bpm

Correct answer:

100-160 bpm

Explanation:

Infants have the highest heart rate of any age group. Normal heart rate for an infant under one year of age is 100-160 bpm. 

Example Question #11 : Procedures And Care

What is a normal heart rate for a school aged child (6-12 years of age) in beats per minute (bpm)?

Possible Answers:

100-140 bpm

50-70 bpm

120-160 bpm

70-120 bpm

Correct answer:

70-120 bpm

Explanation:

Normal heart rate for a child aged 6-12 is 70-120 bpm. This is moderately higher than normal heart rate for an adult, which is 60-100 bpm. 

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